Provider Demographics
NPI:1154748689
Name:WINGFIELD, SHANELL (MFTI)
Entity type:Individual
Prefix:
First Name:SHANELL
Middle Name:
Last Name:WINGFIELD
Suffix:
Gender:F
Credentials:MFTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4441 E KINGS CANYON RD
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93702-3604
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2291 W MARCH LN
Practice Address - Street 2:SUITE C-101
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-6652
Practice Address - Country:US
Practice Address - Phone:916-388-6372
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-21
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF70572106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist